6 research outputs found
The mental health of adolescents and young people experiencing traumatic stress and problematic substance use.
Introduction and Aims: Up to 80% of adolescents have experienced trauma and one-in-seven suffer from post traumatic stress disorder (PTSD). For 50% of these adolesÂcents, the course of their illness is further complicated by a co-occurring substance use disorder (SUD). Despite high rates of comorbidity, treatment options remain sparse and there is limited understanding of the clinical profile associated with this comorbidity. We aimed to examine the clinical profile of adolescents seeking treatÂment for their substance use and traumatic stress.Method: Data were collected as part of a randomised controlled trial examining the efficacy of an integrated psychological treatment for SUD and PTSD among young people aged 12-25 years were assessed for history of trauma, PTSD, substance use and a variety of other domains relating to mental health, social and family functioning and service utilisation.Results: Almost all participants met Diagnostic and StaÂtistical Manual of Mental Disorders, Fifth Edition, criÂteria for a severe SUD. The most common substances of concern were cannabis and alcohol. All participants expeÂrienced multiple traumatic events and >85% met DiagÂnostic and Statistical Manual of Mental Disorders, Fifth Edition, criteria for PTSD. High levels of clinically eleÂvated depression and anxiety were present in the sample and almost half had a history of attempted suicide.Discussions and Conclusions: Comorbid PTSD and SUD in young people are associated with a complex and severe clinical profile. It is imperative to intervene early in the trajectory in order to prevent the severe and long lasting burden associated with this common comorbidity
Comorbidity: Trauma, substance use and mental health
Substance use and mental health disorders commonly co-occur and they are frequently underpinned by history of psychological trauma. This symposium presents new data on the clinical presentation and documentation of trauma exposure, trauma-related disorders, and their treatment among adults entering substance use treatment, the implementation of integrated trauma-focused therapy in substance use treatment, and presenting issues among adolescents seeking integrated treatment for substance use and traumatic stress
New Australian guidelines for the treatment of alcohol problems: an overview of recommendations
Summary of recommendations and levels of evidence
Chapter 2: Screening and assessment for unhealthy alcohol use
Screening
Screening for unhealthy alcohol use and appropriate interventions should be implemented in general practice (Level A), hospitals (Level B), emergency departments and community health and welfare settings (Level C).
Quantityâfrequency measures can detect consumption that exceeds levels in the current Australian guidelines (Level B).
The Alcohol Use Disorders Identification Test (AUDIT) is the most effective screening tool and is recommended for use in primary care and hospital settings. For screening in the general community, the AUDIT-C is a suitable alternative (Level A).
Indirect biological markers should be used as an adjunct to screening (Level A), and direct measures of alcohol in breath and/or blood can be useful markers of recent use (Level B).
Assessment
Assessment should include evaluation of alcohol use and its effects, physical examination, clinical investigations and collateral history taking (Level C).
Assessment for alcohol-related physical problems, mental health problems and social support should be undertaken routinely (GPP).
Where there are concerns regarding the safety of the patient or others, specialist consultation is recommended (Level C).
Assessment should lead to a clear, mutually acceptable treatment plan which specifies interventions to meet the patientâs needs (Level D).
Sustained abstinence is the optimal outcome for most patients with alcohol dependence (Level C).
Chapter 3: Caring for and managing patients with alcohol problems: interventions, treatments, relapse prevention, aftercare, and long term follow-up
Brief interventions
Brief motivational interviewing interventions are more effective than no treatment for people who consume alcohol at risky levels (Level A).
Their effectiveness compared with standard care or alternative psychosocial interventions varies by treatment setting. They are most effective in primary care settings (Level A).
Psychosocial interventions
Cognitive behaviour therapy should be a first-line psychosocial intervention for alcohol dependence. Its clinical benefit is enhanced when it is combined with pharmacotherapy for alcohol dependence or an additional psychosocial intervention (eg, motivational interviewing) (Level A).
Motivational interviewing is effective in the short term and in patients with less severe alcohol dependence (Level A).
Residential rehabilitation may be of benefit to patients who have moderate-to-severe alcohol dependence and require a structured residential treatment setting (Level D).
Alcohol withdrawal management
Most cases of withdrawal can be managed in an ambulatory setting with appropriate support (Level B).
Tapering diazepam regimens (Level A) with daily staged supply from a pharmacy or clinic are recommended (GPP).
Pharmacotherapies for alcohol dependence
Acamprosate is recommended to help maintain abstinence from alcohol (Level A).
Naltrexone is recommended for prevention of relapse to heavy drinking (Level A).
Disulfiram is only recommended in close supervision settings where patients are motivated for abstinence (Level A).
Some evidence for off-label therapies baclofen and topiramate exists, but their side effect profiles are complex and neither should be a first-line medication (Level B).
Peer support programs
Peer-led support programs such as Alcoholics Anonymous and SMART Recovery are effective at maintaining abstinence or reductions in drinking (Level A).
Relapse prevention, aftercare and long-term follow-up
Return to problematic drinking is common and aftercare should focus on addressing factors that contribute to relapse (GPP).
A harm-minimisation approach should be considered for patients who are unable to reduce their drinking (GPP).
Chapter 4: Providing appropriate treatment and care to people with alcohol problems: a summary for key specific populations
Gender-specific issues
Screen women and men for domestic abuse (Level C).
Consider child protection assessments for caregivers with alcohol use disorder (GPP).
Explore contraceptive options with women of reproductive age who regularly consume alcohol (Level B).
Pregnant and breastfeeding women
Advise pregnant and breastfeeding women that there is no safe level of alcohol consumption (Level B).
Pregnant women who are alcohol dependent should be admitted to hospital for treatment in an appropriate maternity unit that has an addiction specialist (GPP).
Young people
Perform a comprehensive HEEADSSS assessment for young people with alcohol problems (Level B).
Treatment should focus on tangible benefits of reducing drinking through psychotherapy and engagement of family and peer networks (Level B).
Aboriginal and Torres Strait Islander peoples
Collaborate with Aboriginal or Torres Strait Islander health workers, organisations and communities, and seek guidance on patient engagement approaches (GPP).
Use validated screening tools and consider integrated mainstream and Aboriginal or Torres Strait Islander-specific approaches to care (Level B).
Culturally and linguistically diverse groups
Use an appropriate method, such as the âteach-backâ technique, to assess the need for language and health literacy support (Level C).
Engage with culture-specific agencies as this can improve treatment access and success (Level C).
Sexually diverse and gender diverse populations
Be mindful that sexually diverse and gender diverse populations experience lower levels of satisfaction, connection and treatment completion (Level C).
Seek to incorporate LGBTQ-specific treatment and agencies (Level C).
Older people
All new patients aged over 50 years should be screened for harmful alcohol use (Level D).
Consider alcohol as a possible cause for older patients presenting with unexplained physical or psychological symptoms (Level D).
Consider shorter acting benzodiazepines for withdrawal management (Level D).
Cognitive impairment
Cognitive impairment may impair engagement with treatment (Level A).
Perform cognitive screening for patients who have alcohol problems and refer them for neuropsychological assessment if significant impairment is suspected (Level A).
Summary of key recommendations and levels of evidence
Chapter 5: Understanding and managing comorbidities for people with alcohol problems: polydrug use and dependence, co-occurring mental disorders, and physical comorbidities
Polydrug use and dependence
Active alcohol use disorder, including dependence, significantly increases the risk of overdose associated with the administration of opioid drugs. Specialist advice is recommended before treatment of people dependent on both alcohol and opioid drugs (GPP).
Older patients requiring management of alcohol withdrawal should have their use of pharmaceutical medications reviewed, given the prevalence of polypharmacy in this age group (GPP).
Smoking cessation can be undertaken in patients with alcohol dependence and/or polydrug use problems; some evidence suggests varenicline may help support reduction of both tobacco and alcohol consumption (Level C).
Co-occurring mental disorders
More intensive interventions are needed for people with comorbid conditions, as this population tends to have more severe problems and carries a worse prognosis than those with single pathology (GPP).
The Kessler Psychological Distress Scale (K10 or K6) is recommended for screening for comorbid mental disorders in people presenting for alcohol use disorders (Level A).
People with alcohol use disorder and comorbid mental disorders should be offered treatment for both disorders; care should be taken to coordinate intervention (Level C).
Physical comorbidities
Patients should be advised that alcohol use has no beneficial health effects. There is no clear risk-free threshold for alcohol intake. The safe dose for alcohol intake is dependent on many factors such as underlying liver disease, comorbidities, age and sex (Level A).
In patients with alcohol use disorder, early recognition of the risk for liver cirrhosis is critical. Patients with cirrhosis should abstain from alcohol and should be offered referral to a hepatologist for liver disease management and to an addiction physician for management of alcohol use disorder (Level A).
Alcohol abstinence reduces the risk of cancer and improves outcomes after a diagnosis of cancer (Level A)
Trialling exposure-based therapy for adolescent traumatic stress and substance use: Challenges and observations from a randomized controlled trial.
Background: For up to 50% of adolescents experiencing PTSD, the course of their illness is further complicated by co-occurring substance use. Despite this, evidence-based integrated treatment options for adolescents with this comorbidity remain sparse. To address this gap, we are conducting an RCT examining the efficacy of exposure-based therapy for co-occurring PTSD and substance use among adolescents. In this paper, we discuss some of the challenges associated with conducting an RCT in the population group and early observations from the trial. Method: A total of 100 adolescents aged 12â18 years will be recruited. Participants are randomized to receive up to 16 sessions of (i) the integrated exposure-based treatment (COPE-A) or (ii) supportive counselling (control). Blind interviews are conducted at baseline, 4- and 12-months. Substance use and PTSD are measured each therapy session. Results: To date, 20 people have been referred to the study with 17 screened for eligibility. A total of 13 were eligible to participate with nine consented and allocated to a condition. Challenges to trial execution include issues relating to the population group itself, involvement of parents/guardians and other health care providers, logistics, ethical and governance approvals, and resources. Discussion: Although there are significant challenges involved in conducting a trial such as this, they are by no means insurmountable. The study findings will improve our understanding of how to best treat PTSD and substance use during this critical develop-mental period. By intervening early in the trajectory ofthese disorders, it may be possible to prevent thesevere and long-lasting burden associated withcomorbidity across the lifespan
Treating trauma and substance use in adolescents
Up to 80% of adolescents have experienced trauma and oneâinâseven suffer from postâtraumatic stress disorder (PTSD), a chronic, debilitating psychiatric disorder. For 50% of these adolescents, the course of their illness is further complicated by a coâoccurring substance use disorder, which often develops from repeated selfâmedication of PTSD symptoms. Once established, both disorders serve to maintain and exacerbate the other leading to extensive social, educational, physical and psychological impairments and a chronic course of illness. It is imperative to intervene early in the trajectory in order to prevent the severe and long lasting burden associated with this common comorbidity. In this presentation we provide an overview of the evidence regarding treatment options available for coâoccurring PTSD and substance use, and promising new early interventions for adolescents. A review of the peerâreviewed literature regarding treatment of PTSD and substance use was undertaken, and best practice approaches for the treatment of adolescents identified. There is growing evidence for the integrated treatment of PTSD and substance use disorders among adults, but the research pertaining to adolescents is in its infancy. Our current trial examining the efficacy of COPEâA will provide much needed evidence as to how these conditions may best be treated in adolescence before they become chronic disabling conditions
Integrated trauma-focused psychotherapy for traumatic stress and substance use: Two adolescent case studies
Post-traumatic stress disorder (PTSD) and substance use disorder (SUD) occur frequently as comorbid diagnoses among adolescents. Historically, these conditions have been treated using a sequential model; however, emerging evidence suggests that an integrated treatment model may be most effective. This article presents two de-identified clinical case studies from an ongoing randomised controlled trial examining the efficacy of an integrated, exposure-based, cognitive-behavioral psychotherapy (CBT) for PTSD and SUD among adolescents (COPE-A), relative to a supportive counselling control condition (person-centred therapy). In both case studies, participants were randomised to receive the COPE-A integrated treatment, which incorporates prolonged exposure (PE) including imaginal and in vivo exposure as a core treatment component alongside CBT for PTSD and SUD. The clinical profile and treatment response of each participant is discussed. Promising results were found in both cases, with substantially reduced traumatic stress symptoms and decreased or stable levels of substance use by the end of treatment. Clinical implications of these early findings are discussed